Navigator Program Intake Form

The personal data collected on the on-line Navigator Intake Form is used to determine your eligibility for admission and to schedule an intake meeting when appropriate. The information is kept confidential.

Please take a few minutes to answer the following questions, so that we can better meet your needs. This form will be part of your child or teen’s medical record, and is confidential.

Required fields *

The Navigator Program helps parents and caregivers caring for a child or teen with complex medical needs. It provides non-medical supports to help parents and caregivers in their caregiving role.

Information about your child or teen:

By completing this web form, you will be asked to share your/your child/youth’s personal information and potentially personal health information. This may include, but may not be limited to, your name, contact information (e.g. email address, phone number), details about you/your child/youth and information about your/your child’s/youth’s previous visits to CHEO. This information is being collected for the purpose of care planning and so that CHEO can better assist in providing support services to you/your child/youth. Your information remains confidential and will not be used for any other purpose, except as required or permitted by law. If you have questions about the use, collection and disclosure of your personal information and personal health information, please contact privacy@cheo.on.ca.